Venice Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Venice Health and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Jul 10, 2025

  Based on record review and staff interviews, the facility failed to protect residents' right to be free from neglect by failing to ensure staff consistently provide safe nursing care to prevent avoidable accidents and serious physical harm for 1 (Resident #1) of 3 dependent residents reviewed.Resident #1 had a history of cerebral infarction (stroke) with resultant hemiplegia (paralysis) of his right dominant side and was dependent on the assistance of 2 staff for bed mobility.On 6/19/25 the Certified Nurse Assistant (CNA) chose to not follow safety precautions of 2 staff assistance listed on the care plan to provide incontinent care, causing Resident #1 to fall out of bed.Resident #1 sustained a serious head injury from the avoidable fall, requiring an emergency transfer to an acute care… […]

• Immediate jeopardy, isolatedF689Jul 10, 2025

  Based on record review, review of facility's policy and procedure, and staff interviews, the facility failed to ensure effective processes were in place to protect 1 (Resident #1) of 3 residents reviewed from avoidable fall and fall related major injury.Resident #1 had a history of cerebral infarction (stroke) with resultant hemiplegia (paralysis) of his right dominant side and was dependent on the assistance of 2 staff for bed mobility.On 6/19/25 the Certified Nurse Assistant (CNA) chose to not follow safety precautions of 2 staff assistance listed on the care plan to provide incontinent care, causing Resident #1 to fall out of bed.Resident #1 sustained a serious head injury from the avoidable fall, requiring an emergency transfer to an acute care hospital for evaluation and… […]

• Actual harm, isolatedF689Jun 7, 2023

  Based on a review of facility policy and procedures, record review, and staff interviews, the facility failed to accurately assess and reassess risk factors and provide necessary supervision and assistance to prevent falls, for 1 (Resident #4) of 3 residents reviewed who were identified as being at risk for falls and sustained multiple falls at the facility, including a fall with injury requiring the resident's transfer to a higher level of care. The findings included: A review of the facility policy and procedure, Falls Prevention program, stated that each Resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. […]

• No harm, potential for more than minimal, widespreadF803May 14, 2026

  Based on observation, record review and staff interviews, the facility failed to have menus that were prepared in advance and reviewed by a dietitian or other clinically qualified nutrition professional for nutritional adequacy.The findings included: On 5/11/26 at 9:15 a.m., upon request, the Certified Dietary Manager provided the facility's menu for the week of May 10, 2026, through May 16, 2026. There was no documentation that the menu was reviewed by a dietitian. In an interview, the Certified Dietary Manager (CDM) said that she was only able to supply a menu for the current week and verified that the menu was not signed by a dietitian. The CDM said that the facility's contract with a food management company ended a few weeks ago and the company pulled everything from the kitchen. […]

• No harm, potential for more than minimal, widespreadF812May 14, 2026

  Based on observation and staff interviews, the facility failed to store food in accordance with professional standards for food service safety.The findings included:On 5/11/26 at 9:09 a.m., observation of the kitchen with the Certified Dietary Manager (CDM) revealed the following:The temperature log for the reach-in refrigerator noted April 2026 under Location name. The log did not have a temperature documented for 5/11/26 at 5:00 a.m. On 5/11/26 at 9:12 a.m., observation of the reach-in refrigerator revealed 8 unlabeled filled beverage pitchers.On 5/11/26 at 9:15 a.m., upon request of facility's policy for storing and labeling food, the CDM said that the facility did not have dietary policies and procedures. […]